Health Information Services

To request copies of your medical records, please follow the instructions below. Be sure to download and sign the release form.

Authorization to Release Information Form

Instructions for filling out the "Authorization to Release Information" form if you are the patient. If you are requesting records on someone other than yourself, please contact HeIS Correspondence at (207)973-7877 to find out what may be needed.

1. In the patient identification box found in the upper left hand corner of the form, please write:

Your name (Please provide maiden or previous last names for which records would be located under, as well as your current last name)
Mailing address
Phone number
Date of birth

2. On the line below the patient identification box, please write your name.

3. On the lines provided for the name of the person(s) to whom records are to be released to, please write the name, address and phone number for each recipient. If the information is for you, the patient, just write "self".

4. Where the form lists: "Purpose", please write one of the following below:

If the information will be sent directly to you, write "personal"
A physician or another healthcare facility, write "continuing care"
A lawyer, write "legal"
An insurance company, write "insurance claim"

5. Next you will see two boxes to be checked.

Check the first box if you are completing the release during an admission (inpatient or outpatient) or a "series" visit you may be in, i.e., any therapy (speech, physical, or occupational), chemotherapy treatment, radiation treatment, or even labs.
Check the second box if you are looking for a specific record(s). Please try to give the date(s) for which the treatment(s) took place and the type of treatment you received. To cut down on any costs, you can request the "abstract" of the record(s). This will include all physician reports and test results, i.e., all "imaging" tests (x-rays, CT scans, ultrasounds, sonograms, etc.), and all cardiology tests.

6. The next line on the release states "Unless I revoke this authorization, it will expire in 12 months…" You can write a specific date that the release will expire if you like.

7. The next line on the form says: "Other information to be given or other comments:" This would be if you are requesting something different, other than the "abstract" you wrote above. You may only want a discharge summary or other physician's report, or just a certain test result. Please write it here.

8. There are three questions that we are required to ask all people requesting medical records according to mandates of the State of Maine. We need the patient's or authorized representative to give us permission to release records that pertain to the treatment or diagnosis of drug or alcohol abuse, mental health, HIV infection, ARC or AIDS.

If you know these records will not contain such information, you may cross them out.
On questions 1, 2 (part 1) and 3, if you circle "I DO", that means you are giving EMMC permission to process and send these records out.
If you do not want that information released, circle "I DO NOT"
On question 2 (part 2), which pertains to mental health treatment or diagnosis, circle "I DO" if you wish to review the information (*please see note below) before it is released and "I DO NOT" if you do not wish to review.

*The State of Maine law states we cannot release a psychiatric evaluation or mental health record directly back to the patient, as it may be detrimental to that patient's health. You, the patient would have to call the Health Information Services' department to set up an appointment to have supervision by a treating clinician or designee and the bottom of the release would be completed by them.

To avoid this procedure, you can request these types of reports or records to be sent to someone other than yourself.

9. Lastly, sign on the patient line and date the form.

Mail to:
Health Infomation Services
Eastern Maine Medical Center
43 Whiting Hill Rd. Suite 100
Cianchette Building
Brewer, Maine 04412

Remember…If you want records on any patient, other than yourself, you must contact our department for further instructions on what may be needed.

Please feel free to call us at (207) 973-7877.

Sincerely,
Health Information Services